Moments That the Words Don’t Reach

Casimiro PT / shutterstock.com

There are moments that the words don’t reach
There is suffering too terrible to name
You hold your child as tight as you can
And push away the unimaginable
                                    —Lin Manuel Miranda

A friend of mine was killed a few days ago.

By the time you read this column, the scars will have already started to form. When I wrote these words, however, the wounds were still fresh.

In my first conception of this article, I was going to provide a detailed description of exactly what happened to her as she sat at the intersection in northern Baltimore County. I ultimately decided it was unnecessary; no matter the specifics of this tragic event, the fact remains that she was taken from us far too soon.

As a physician, of course I’ve encountered death before, but never the death of someone whose presence I felt so deeply in my life.

When people heard us argue in the hallways, some would turn and run in the other direction. Even more would pull up a chair to watch the show. My friend, a former trainee, sought me out in our clinic workroom several times weekly. She seemed to start every conversation with the premise that she was right about something and I should apologize for having, somehow, grievously wronged her. I would retort that I was sitting in the workroom to, well, work, and if I was always in the wrong, why was she constantly interrupting my work to ask for my opinion?

And thus, an argument would begin. I know to the casual observer, it looked like a brawl. But if you looked carefully, you would see it was actually a pas de deux, carefully choreographed with dramatic gestures and mimed feints. Each always knew to reach out before the other could fall. I miss those arguments, already.

The Kübler-Ross stages of grieving have been criticized for being inaccurate or incomplete.¹ Contrarily, I am always struck by how much they seem to capture. When I received the news, I was in denial, which allowed me to turn around an obituary for publication in about an hour; it was almost like writing a work of fiction. When I learned the identity of the perpetrator, I experienced anger in a way I will not describe in these pages. I found deal-making has been part of my coping mechanism; from time to time over the past few days, I have found myself wondering when she would be back from her annual vacation with her family. And finally, depression. Just from a scientific standpoint, I’ve found it fascinating that I can be perfectly functional one minute and burst into tears the next.

I’m surprised to say The Boss got me through the first 24 hours. I learned of my friend’s death the same day Netflix posted its recording of Springsteen on Broadway. Unlike virtually everyone else who grew up on Long Island in my generation, I was not an overt fan of Bruce Springsteen. That said, he was pervasive, woven into the fabric of my childhood summers, more than I had even realized until that moment. The familiar music was like a cat, purring on my lap. I let the video play, twice, on low, as I took turns comforting and being comforted by my colleagues and friends.

Grief, of course, is a luxury reserved for those who do not have a full clinic. The day after my friend died, I looked at my schedule, and I sighed. I sometimes joke that there are days when I wish I could tell patients: I know you need me to be sympathetic. I just don’t have it in me today. Come back tomorrow; I’m happy to be sympathetic then.

I was about to start a week’s worth of those days. The patient with intractable pain whose orthopedic surgeon kept insisting had an active rheumatic disease as the cause. The patient with polymyalgia rheumatica who flew up from Florida because he is convinced he now has giant cell arteritis. In a normal week, I would just go with it, but now, I really just wanted to be left alone to wallow in my thoughts.

The Trauma of Sudden Death

I learned that I was experiencing the consequences of sudden death. I was previously familiar with the term sudden cardiac death, which typically refers to an arrhythmia. Sudden death refers to anyone who dies unexpectedly, most often from an accident, homicide, suicide, disaster or an acute medical condition.² The concept exists hand in hand with sudden bereavement, which is the mourning a survivor experiences when he or she has not had time to prepare.

Physicians can often see death’s approach long before the sickle is sharpened. Patients’ families also learn the gradually accelerating rate of hospitalizations likely signals an impending demise. There is time to start the grieving process even before the loss is experienced.

The Kübler-Ross stages of grieving have been criticized for being inaccurate or incomplete. Contrarily, I am always struck by how much they seem to capture.

In the case of sudden death, such preparation is not possible. Thus, the survivor is forced to experience a symphony of emotions at a single moment in time.

Therese Rando, a clinical psychologist at the Institute for the Study and Treatment of Loss in Warwick, R.I., describes it as follows: “They’re not just dealing with loss. They’re also dealing with personal traumatization. … It affects the ability to get on with grief and mourning, to bend your mind around what has transpired. There is no warning, no time to prepare and gradually take on the notion. … A person is not just heartbroken when they lose someone suddenly. They’re heartbroken, and they’re traumatized, and they’re put in a situation where the conflicting needs of dealing with the heartbreak and trauma simultaneously can impede their forward process for a while.”³

Describing this loss as a trauma is a common theme. The most common reaction to the trauma is shock, which causes the victim to feel numb or disconnected to their feelings. Another phase not described by Kübler-Ross is guilt: guilt over surviving, over words not said, over one’s own reaction to loss.⁴

Coping with Sudden Death

How someone deals with this trauma while still showing up to work is highly dependent on the individual; everyone grieves in their own way, and for some, going back to work may be part of that process. Some recommendations include the following:⁵

1. Don’t isolate: Although a natural impulse in many cultures is to mourn in isolation, it is better to be with friends and family, who could provide emotional support as you heal;
2. Express your feelings: Tears are a normal and natural part of grieving; suppressing these emotions may lead to other behaviors, like overeating or angry outbursts;
3. Take advantage of available resources: Many universities and hospitals have counseling programs for employees dealing with trauma. A counselor may help you determine how to reintegrate into your workplace as you grieve;
4. Keep in mind that you may not be at your best: Grief may interfere with your ability to concentrate at work, and it may help to temporarily reduce your work schedule; and
5. Be good to yourself: It is important to remember to take care of yourself, which may include exercising and meditation.

If you are part of someone’s support system, these are some things you could consider:

1. Reach out: Send an email or a text, make a phone call, or stop by to visit. As someone who has provided support for others, this always feels awkward; as someone who has needed support, every gesture has been welcome;
2. Communicate: Having someone to listen to you can be enormously therapeutic, as can telling stories about the person who died;
3. Create a safe space: As a non-millennial, I detest this expression. That said, it applies here; encourage the griever to express whatever they are feeling, without holding back; and
4. Grief takes time: People are often surprised by how long it can take to complete the grieving process. In Judaism, the loss of a parent is mourned over four stages, acknowledging that grief continues to evolve over long periods of time before it completely dissipates.

As for me, I have found that I can hear my friend’s voice in my right ear. There is an old story about how everyone has a devil perched on his left shoulder, urging him to do bad, and an angel on his right, urging him to do good. I seem to hear her voice only on my right; I am sure she would be insulted by my surprise. But there it is, providing a commentary on my actions, disapproving when I don’t give my full effort, urging me to be a better man. I have come to think of this voice as a gift. I hope it doesn’t fade too quickly.

In the meanwhile, I have abandoned The Boss, and have started to listen to the Hamilton soundtrack. Both have so many songs about lost lives and lost opportunities; I think that is why both are helping me cope. I play the soundtrack on my commute to work, in place of the news programs I can no longer bear to listen to.

They say that “80% of success is showing up.” So instead of crawling back into bed, I listen to that voice in my right ear, and show up to work and take care of my patients, as I learn to live with the unimaginable. 

Philip Seo, MD, MHS, is an associate professor of medicine at the Johns Hopkins University School of Medicine, Baltimore. He is director of both the Johns Hopkins Vasculitis Center and the Johns Hopkins Rheumatology Fellowship Program.

References

1. Feldman DB. Why the five stages of grief are wrong. Psychology Today. 2017 Jul 7.
2. Knittel MG. Grief following sudden death of a loved one. Psychology Today. 2016 Oct 4.
3. Etheridge P. Going on after sudden loss of a loved one. CNN. 2014 Apr 2.
4. Raab D. What everybody should know about survivor’s guilt. Psychology Today. 2018 Jan 26. .
5. Castaneda R. How to balance work demands while grieving a sudden death. US News and World Reports. 2017 May 3.